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ture and lose their epithelium leaving super- Thus, there have been cases where dentists ties like HIV or uncontrolled diabetes. The
ficial spreading ulcers in their wake. These and physicians erroneously identified pem- recurrence of Herpes Zoster (shingles) is
superficial ulcers begin to heal by first cre- phigus, aphthous stomatitis, rubella and uncommon; however, vaccination is still
ating a soft crust followed by a hard crust or rubeola via differential diagnosis, most like- encouraged even if the patient has presented
scab. The most serious complication is pos- ly not realizing that HZ was a possibility in with shingles in the past. 15
therpetic neuralgia which is debilitating. It the oral cavity (Figure 7). In one example,
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is characterized by pain or dysesthesia that Covid-19, Sars CoV 2 and the Possible
persists after the rash resolves. Postherpetic Connection to Herpes Zoster:
The emergence of COVID-19 has also in-
neuralgia occurs in 10% -18% of patients troduced another facet to HZ. In December
with HZ. The severity of the pain ranges 2019, Wuhan, China reported the first case
from mild to excruciating. 8, 9 of pneumonia caused by COVID-19. Since

There is a major misconception that HZ can its emergence, cases of HZ are on the rise.
As the virus continued to spread, the num-
only manifest in the trunk, when in fact it ber of COVID-19 cases reported with HZ as
may affect any sensory (dorsal) ganglia, the a comorbidity became more frequent, sug-
peripheral sensory nerves, and their corre- gesting there is a possible link. In fact, sev-
sponding cutaneous nerves. Unfortunately, Figure 7. Herpes Zoster on the lips. eral skin manifestations have been reported.
this misconception can extend to medical Thus, it is suggested that individuals that
professionals as well and can lead to mis- a patient presented with painful vesicles and have been diagnosed with HZ or other un-
diagnosis, or lack of diagnosis (Figure 6). erythematous lesions on the right side of the explained lesions should be advised to get
face. The ulcers also appeared on the hard tested for COVID-19 during the pandemic.
palate and were acutely painful (Figures Indeed, preliminary research has shown that
1-3). This is a classic example of how an COVID-19 does, in fact, impair antiviral
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oral healthcare professional diagnosed HZ, responses. This revelation would appear
since the patient presented with unilateral to make COVID-19 a likely candidate for
lesions on the palate and the face that could reactivation of HZ. But what is the actual
be easily seen by inspection and was not mechanism for this to occur? As stated,
limited to the trunk. 13 VZV needs an etiologic factor to allow for
HZ reactivation as VZV tends to remain
Presentation of HZ in the mouth can also be in a latent state until reactivated, (which
misleading as well. Intraoral characteristics is probably related to neuronal resistance
consist of aphthous stomatitis appearance to VZV-induced apoptosis). COVID-19
Figure 6. Herpes Zoster on the cheek. (once the vesicles have ruptured), which can can directly infect lymphocytes, especial-
be confusing clinically when the midline of ly T-cells, which can lead to lymphopenia.
While the most common sites affected are the rash is not well defined. Extraoral char- Lymphopenia and damaged CD4+ T cells
can cause an impaired antiviral response via
thoracic dermatomes (56%), it can also af- acteristics consists of tingling and burning a decreased immune system. Paired with
fect the cranial (13%), cervical (11%) and sensations up to 3-5 days prior to the rash. the other associated stressors of COVID-19
sacral nerves (4%). It is the cranial nerve It is important to note that while the vesi- it would appear that it can ultimately trigger
involvement that dentists and dental hy- cles can not only appear on the face or in the the reactivation of the HZ virus. In addi-
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gienists can have the most impact in early oral cavity, they also characteristically stop tion, other cutaneous signs of HZ related
detection and treatment. Among the cranial at the midline of the body, and thus can be to COVID-19 infection are emerging on a
easily distinguished from many other disor-
nerves, the trigeminal and the facial nerves ders. 14 regular basis. There is evidence of a role for
are the most affected, due to reactivation of COVID-19 in the development of cytokine
HZV latent in the ganglia. Age/Sex/Race: Generally, HZ effects the storm in a subgroup of patients with severe
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elderly, immunocompromised and predom- infection. COVID-19 may have fostered
The first division of the trigeminal nerve inately Caucasian, although it can occur in retrograde reactivation of VZV from the na-
(ophthalmic)is commonly affected, whereas any age group or race. sal cavity, where the ophthalmic and max-
the second (maxillary) and third (mandib- illary branches of the trigeminal nerve are
ular) are rarely involved. It is important to Treatment: The primary objectives in treat- harbored. Hence, COVID-19 is implicated
consider that during the prodromal stage, ment are to manage acute pain, promote in this rare presentation of HZ as well. 18
the only presenting symptom may be odon- healing of the associated rash, and most
talgia (toothache) which may prove to be importantly, prevent post-herpetic neural- Herpes Zoster (Shingles) References
a diagnostic challenge for physicians and gia. Currently, the recommended therapeu- 1. Wood, Martin J. “History of varicella zoster
virus.” Herpes: the journal of the IHMF 7.3
dentists. Occasionally Herpes Zoster can tic treatment is an oral antiviral/systemic (2000): 60-65.
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affect the tip of the nose which in innervated medication (acyclovir, Valacyclovir, Fam- 2. Gershon, Anne A., et al. “Advances in the un-
by the nasocilliary branch of the ophthalmic ciclovir) to be initiated at the first sign of derstanding of the pathogenesis and epidemiolo-
nerve. This is known as a Hutchinson’s sign the disease or as early as possible. Taking gy of herpes zoster.” Journal of clinical virolo-
and can lead to blindness. Treatment is tar- the prescribed antiviral medication early in gy 48 (2010): S2-S7.
geted to the involved area, often including the course of the disease decreases the like- 3. Kyriakou, G., et al. “Pathophysiological and
lihood of post herpetic neuralgia. It is ad-
Epidemiological Aspects of Herpes Zoster: A
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antiviral ointment and drops. Topical ste- visable for patients who have had varicella Short Review.” GSL J Public Health Epidemi-
roids should be avoided in those with active virus (chicken pox) to receive the shingles ol 1 (2018): 105.
corneal epithelial disease. 11 vaccine as soon as they are able to, at age 4. Shah, Radhika A., et al. “Shingrix for herpes zos-
50 or earlier if they have other co-morbidi- ter: a review.” Skin therapy letter 24.4 (2019): 5-7.
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